Surgery News - April 2008 - (Page 8)

GENERAL SURGERY SURGERY NEWS • A P R I L 2 0 0 8 Metabolic Syndrome Prevalent Bariatric • from page 1 were black, and 5% were Hispanic. The researchers defined the metabolic syndrome as morbid obesity plus two or more of the following: hypertension, diabetes, and hyperlipidemia. The main results of the study—which analyzed gender, ethnicity, morbidity, and mortality—were the following: The prevalence of the metabolic syndrome among bariatric surgery patients was higher than previously reported by the National Health and Nutrition Examination Survey (NHANES) III study (27% vs. 23%). Overall morbidity after bariatric surgery was significantly higher in patients with the metabolic syndrome than in morbidly obese patients without the metabolic syndrome (8.6% vs. 5.8%). Mortality was similar between the two groups (0.04% vs. 0.01%). Hispanics with the metabolic syndrome had the highest morbidity rates, followed by blacks and whites. Males had higher mortality than females. In-hospital bariatric surgery outcomes were significantly better in patients who had laparoscopic gastric banding than in those who had gastric bypass. Laparoscopic gastric banding was associated with fewer complications (3% vs. 10%), shorter length of stay (1 vs. 3 days), and lower in-hospital costs ($9,000 vs. $13,000) than was gastric bypass. The higher complication rates in patients with the metabolic syndrome indicate that these patients might benefit from less invasive procedures, such as laparoscopic gastric banding, said Dr. Varela, who also is director of minimally invasive surgery for the VA North Texas Health Care System. He added, however, that this hypothesis needs to be tested further before any clinical recommendations can be made. Long-term studies evaluating the efficacy of these bariatric procedures in resolving the metabolic syndrome in morbidly obese patients are warranted. The finding that the metabolic syndrome was higher among the Hispanic population had been observed previously, he noted. Asked to comment on the results, Dr. Myriam Curet said that common obesityrelated comorbidities—components of what is now called the metabolic syndrome—have previously been recognized as risk factors for increased complications after any type of surgery. But this study demonstrates the association using a large clinical database, and the results are more translatable to a broad range of practices than those of studies from single institutions with a few hundred patients, said Dr. Curet, an ACS Fellow who is a bariatric surgeon and professor of surgery at Stanford (Calif.) University. She found the data on ethnic differences noteworthy because it has been recognized that men do worse than women, and that black women tend to do worse than white women after bariatric surgery. These results reveal other issues that need to be investigated, Dr. Curet said in an interview, citing the need to determine whether something can be done before surgery to reduce risk and to counsel patients about the potential risk factors. “Defining who are the appropriate candidates [and] who are high-risk candidates, and deciding what we can do for those high-risk candidates to make them lowerrisk candidates are clearly important issues,” Dr. Curet said. She cautioned against assuming that less invasive procedures are better for higher-risk patients. Some complications with laparoscopic banding are less severe than with gastric bypass procedures, but other complications and the need for reoperation are the same as or higher than they are with laparoscopic banding, she explained. Endoscopic Management Beneficial for Bile Duct Injuries B Y J E F F E VA N S Else vier Global Medical Ne ws H O T S P R I N G S , VA . — Endoscopic management of postcholecystectomy bile duct injury prevents recurrence in many patients and eventually resolves most strictures in the minority of patients with recurrences, making it nearly as successful as surgery, according to Dr. Gary C. Vitale. In a series that Dr. Vitale presented at the annual meeting of the Southern Surgical Association, he reported that bile duct injuries occurring after cholecystectomy resolved in 78% of patients treated with endoscopic retrograde cholangiopancreatography (ERCP), compared with published series reporting good outcomes in 83%-95% of patients undergoing hepaticojejunostomy—the traditional treatment for such injuries—and in 80%91% of patients treated with ERCP. “I think that most of us would agree that it’s controversial whether [bile duct injuries] should be managed endoscopically. I think that most people think that if you’ve got such good results endoscopically [then] either you haven’t followed them up long enough or you weren’t dealing with the same strictures,” said Dr. Vitale, an ACS Fellow and professor of surgery at the University of Louisville (Ky.). But “we’re certainly in the same ballpark” in comparing the outcomes of endoscopic treatment of bile duct injuries with those treated surgically, he said. Bile duct injuries, which occur in about 0.1%-0.2% of open and 0.4%-0.6% of laparoscopic cholecystectomies, are a lifethreatening complication that can lead to biliary peritonitis and sepsis. Only about one-third of such injuries are recognized initially, Dr. Vitale said. He reviewed a series of patients who had postcholecystectomy bile duct strictures and transections that he and a colleague initially diagnosed with ERCP during 1991-2006. They treated incomplete transections and strictures with balloon dilatation and stenting, and reserved surgery for complete obstructions in- volving long strictures or loss of tissue. Of 292 patients with a possible bile duct injury, Dr. Vitale and his associate reported 199 with an iatrogenic injury. They reviewed the results of 67 patients with a mean age of 45 years (range of 17-87 years) who met the Amsterdam classification criteria for type B (major bile duct leakage, which occurred in 30 patients), type C (stricture of the common bile duct, which occurred in 18), or type D injuries (complete transection of the common bile duct, which occurred in 19). These patients were treated with either ERCP (48) or a hepaticojejunostomy (19); two of the patients who underwent ERCP required an early conversion to hepaticojejunostomy because of intolerance of stenting and a cholangiocarcinoma. In follow-up clinical visits, stents were removed and replaced every 3-4 months for the first 11-14 months. Once the stents were removed, routine follow-up visits were scheduled every 6 months for the first year and then annually thereafter. Dr. Vitale said that patients who missed office visits were telephoned. He and his colleague considered a bile duct injury resolved when patients were asymptomatic and the bile duct diameter in the injured area was restored to normal or less than 20% narrowing. In all remaining 46 cases that were treated with ERCP, the investigators achieved 100% cannulation of the injured bile ducts. Only three patients needed an early change of stents for cholangitis, and another four patients had mild pancreatitis the resolved within 2-3 days. Overall, 60% received balloon dilatation, and many patients were double-stented (19) or triple-stented (10). During a mean follow-up period of 31 months, strictures resolved in 36 (78%) of the 46 patients. Strictures recurred in the other 10 patients, who became symptomatic 12-24 months after treatment. Of those, six responded “quickly” after one or two ERCP treatments, and four required surgery. “I think the advantage of having surgeons look at these at the outset and mak- A common bile duct stricture (left) was caused by injury post laparoscopic cholecystectomy. Balloon dilation of the stricture is shown at right. The bile duct stricture is shown after balloon dilation (left). Three stents have been placed in the bile duct (right). ing that triage probably counts in a great way for the good results that we had endoscopically,” Dr. Vitale said. “The decision regarding surgical or endoscopic management of this complication requires careful consideration of many factors, such as location and classification of the injury, and time of presentation,” said Dr. Gerald Fried, who commented on the study. “It is also very important to know the results of treatment in your institution and that of institutions to which you refer patients sustaining bile duct injury,” added Dr. Fried, an ACS Fellow and professor of surgery at McGill University in Montreal. “A high index of suspicion is required for early recognition and repair, [which] certainly helps these patients,” Dr. Vitale said. “When a bile duct injury is recognized intraoperatively and there is expertise available to manage the problem surgically, there is much to be said for performing a definite reconstructive procedure at that time,” said Dr. Fried, adding that when diagnosis of the injury is delayed, it is often best managed endoscopically “with the expectation, in expert hands, of very good outcomes as reported by Dr. Vitale.” PHOTOS COURTESY DR. GARY C. VITALE

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Surgery News - April 2008 Contents Comorbidities Sway Bariatric Outcomes Database Finds Gap in Dissection For Melanoma Future Surgeon Shortage Predicted Dexterity Demo Best for Bile? Health Policy Scan Plan

Surgery News - April 2008

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